EMERGENCIES IN DERMATOLOGY Acute Skin Failure

ICU in the Skin department Prof Rene Touraine first established an ICU in the skin Dept. in 1974 Now recognized as a necessity due to large number of extensive skin diseases eventuating into the potentially fatal syndrome of ‘acute skin failure’

Emergency - Defined ‘A risk perceived by a doctor or a patient to life, limb or the structure / function of an important organ of the body’

Consequences Disfiguring dermatoses can generate emergency situations Disproportionate and spectral psychocutaneous morbidity Disruption of psychosocial function of self worth and emotional expression Disrupt interconnected anatomy and physiology of skin

Emergencies Anaphylactic Exanthematous Acute eczematous Urticarial / angioedematous Purpuric Photosensitive reactions SJS - TEN

Emergencies in New born Purpura fulminans Lamellar desquamation Infantile acute hemorrhagic oedema Sclerema neonatorum Congenital absence of skin and metabolic disorders like porphyrias

Etiopathogenesis Failure of skin to perform its multiple functions can lead to Acute failure of heart, lung, kidney and death consequent to structural and functional alterations in various components of the skin

Stratum Corneum Destruction of Stratum corneum Increase in fluid loss by 40 times 50% of BSA involvement leads to daily fluid loss of up to 4-5 litres Loss of proteins, Na, K, Cl in the bullous fluid leads to a decreases in intravascular volume Resultant decrease in urinary output and increase in blood nitrogen can lead to renal failure

Altered barrier function Damaged skin + exudates support growth of microorganisms Systemic infections, severe sepsis and death Altered immunological function

Common dermatoses leading to acute skin failure Exfoliative dermatitis Bullous diseases Pemphigus vulgaris Bullous pemphigoid Erythema multiforme Toxic Epidermal Necrolysis

Exfoliative Dermatitis Erythema and scaling involving a large BSA Psoriasis – the most common antecedent illness Miscellaneous causes include ichthyosis, pemphigus, TEN, crusted scabies, etc Intake of drugs like sulphonamides, dapsone, antiepileptics, penicillins, etc 10 – 15% of the cases

Bullous Disease Immunobullous diseases like pemphigus Pemphigoid, etc Hereditary mechanobullous disorders like epidermolysis bullosa can be life threatening

Pemphigus Vulgaris There are 3 main types of pemphigus P. foliaceous (blister in the superficial granular layers P. vulgaris ( the blisters just above the basal layer) Paraneoplastic pemphigus that occurs in association with malignancy

Lesions in Pemphigus Flaccid blisters Erosions Nikolsky’s sign is positive Oral mucosal involvement is universal

Bullous Pemphigoid Subepidermal blistering skin disease of the elderly Characterized by large, tense, bullae arising on normal or erythematous skin Eroded skin tends to reepithelise Drugs like penicillin, furesemide, sulfasalazine, penicicllamine, captopril, etc, local trauma, burn wounds, grafts, irritants, UV radiation and malignancies like carcinoma in stomach can precipitate this disease

Erythema Multiforme An acute, self limiting, mucocutaneous reaction pattern to many viral, bacterial, protozoal and fungal infections, tumors, drugs, autoimmune states and miscellaneous conditions

Clincial Spectrum Symmetrically distributed polymorphic rash Target lesions seen on hands with a central vesicle or erythema surrounded by a pale and then a red ring

TEN Extensive denudation of skin is the hallmark of TEN Mortality rate – 40 – 50% Malaise, pruritis, fever, prostration and myalgia are common

Acute Skin Failure - Management Twin management principles Prompt initiation of appropriate treatment Excellent double barrier nursing care

Acute Skin Failure - Management Careful observations on Heart rate Pulse rate Urinary volume monitored hourly Urinary osmolarity Glycosuria Temperature Gastric contents monitored 3 – 4 hourly Any change in extent of skin lesions and body weight

Acute Skin Failure - Management Correction and maintenance of hemodynamic equilibrium by fluid and electrolyte administration Aggressive nutritional support Judicious use of antibiotics – to avoid strain selection, fungal infection and drug reactions Topical antiseptics like silver sulphadiazine Specific therapy – based on the underlying cause

Summarizing… Sudden severe alterations in the anatomy and physiology of skin consequent to generalized dermatoses can lead to disabling complications Understanding the etiopathogenesis and their prompt management in ICU on lines similar to that of burns can salvage many lives